Category Archives: In the media

I received a tweet this morning – “Telerehab+fall predict platform= Game changing. Effective?” (I tried to embed it but it wasn’t working). The American Telemedicine Association is having their meeting in Minneapolis this week, and it will include telehealth platforms for seniors. Two quick thoughts about the idea before I get ready for work (I’d love your comments and thoughts in the comments or on Twitter).

First, I agree with the author of the article that cost will be a huge issue. Those on a fixed income are not going to have much wiggle room, and those who are poorer and rely on SS definitely will not. This will be an increasing concern with the Baby Boomers given the data out there on their savings (or lack of) for retirement.

Second, will THEY want to wear it/ use it? There is a great section of dialog in Jurassic Park where the grandfather is defending all he has done to the scientists, that he spared no expense, and Ian (Jeff Goldblum’s character) says something to the effect of your scientists were so busy asking if they could they didn’t ask if they should. In the same vein, are we so busy asking if we can do all this great tech we aren’t asking whether they want it? Yes, there are those who love tech and will embrace the idea, but are those the ones that are having the falls, experiencing incontinence, not eating well, etc? It reminds me of the Fitbit – those who use it are often the ones who are already fit. Will they view it as an invasion of their privacy, of one extra step closer to an ALF or a nursing home, despite assurances that the tech is “to keep them as independent as possible for as long as possible”?

I think the technology has the potential to be effective, and to be a game changer for many. But I think that for many others the financial cost and the resistance against the tech intrusion will require continued personal monitoring and involvement by family and the home health community.

I’ve been thinking for some time now (starting during PT school, because of my father and grandfather getting older) about the aging population – including illness, chronic illness, health and wellness, the changing of demographics in the communities and what is needed, or better yet, what might be expected and how to get ahead of the changes. It was one of the reasons I did the residency and earned my GCS, and with continued changes to healthcare I’m realizing that instead of responding to just a major or minor illness (in my daily practice), I also need to get ahead and do something to help address population health. From what I’ve seen communities are becoming more aware of this as well as their population ages, including Washington County and the Twin Cities overall.

Dr. Michael Riley has written a great challenging blog post Can We Jump the Fence? which I encourage you to read as a starting point. One thing he writes is “Given the current health climate we are not seizing the opportunity to work as the entry point to better health. People change for two reasons, desperation or inspiration… I have been inspired to change the way I think about the future of this profession and the value we possess.”

Practice Level: How can we do this at a provider level? For PT’s working with older adults, we need to be inspired to be the entry point, and to view our position as a both-and (prehab/wellness, rehab, and post-hab/ wellness so to speak), not as either-or (PT or personal trainer, for lack of a better term). The issues I see for those working with older adults is that Medicare won’t pay for wellness, there is an annual limit for MedB (and a rather tight scrutiny if you go over), and the limited fixed income most seniors are on create limits in some way. Even if all these were answered to our patients’ benefit, there is a significant issue with adherence to exercise in the older adult population. So how can we jump the fence and be “the entry point to better health”? We can advocate on our own, but having the support of other providers and current and former patients will be important.

Get buy-in from other providers. They need to know what we can do, both for injuries and to address chronic diseases. We need to show we know what we are doing by challenging our patients (which we don’t do often enough) to demonstrate good results. Two PT’s who stick out in my mind in challenging the strength of their older patients or clients are Dustin Jones of the Senior Rehab Project and Christina Nowak of STAVE Off.

Get buy-in from our patients (the customer) that we are THEIR therapist, not just for this POC but anytime the need arises. How can we do this? Practice at our best, every, single, time; don’t give out a generic HEP, but target it to the patient’s most significant impairments (and emphasize this); and provide home assessments if they are interested.

Community Level: This will largely be a pro-bono effort initially (though some customers may come your way through your interactions), but it is greatly needed, though others have found a way for it to work for the general population (see the link below for Pro-Activity Associates). Having the support of providers and older adults may help you get a program started or give you ideas for promoting healthy aging in your communities.

For older adults: support or even teach programs for falls prevention and strengthening; teach a class at your community center or local gym on a wellness topic or recovery from [x]; make or find and promote low cost technology to encourage physical activity in the older adult population. An example of a good community program for overall health is Mike Eisenhart’s Pro-Activity Associates (What might a geriatric version of this look like? I’m intrigued and excited by the idea).

For their families: advertise how your program or classes can help their loved one function better; offer home assessments to help them age in place.

For communities and businesses: first, ask older adults what they see that they will need as they age! Second, you can provide input at city, county or state meetings (zoning, transportation, and parks are a few areas that come to mind) where issues may come up that relate to older adults. You can also provide comments to businesses on how to be senior friendly, and offer input to senior centers and ALF’s on design changes and fitness facilities. Eagan, MN is redesigning their town (which is great for those who can move), maybe your community will redesign a part or all of it to accommodate older adults. If you aren’t sure where to get started, contact your community’s public health department, and help out where your community may note needs (Washington County seems to have a good grasp of where the needs are and what they have in place already).

With a new baby I’m not taking on anything new at the moment, but I’m mulling all this over in my mind. How can I help position physical therapy as “an entry point to better health”? Can we therapists network with each other and with other disciplines and organizations to elevate the health and wellness of our aging population? I think the answer is yes. I’d love to hear your ideas either in the comments below, on social media, or via email.

There has been a recent discussion on the geriatrics listerv about productivity (and a recent PT in Motion article about productivity), but you can probably read it anywhere on any discussion forum for rehab professionals – productivity requirements continue to rise, and it is making professionals frustrated. I said in a tweet it makes me sad, angry, and a little scared for our profession. I want to write a bit more on that.

First, how productivity is calculated: I work in a facility that calculates productivity based on minutes billed divided by hours present per day, minus any CEU time (if it takes me 30 minutes or 90 minutes for an eval, I bill 30 minutes or 90 minutes – I would take issue with some place that only allows me to bill or account 45 minutes for an eval if it takes me 60 from a professional perspective). In my career I’ve worked in 3 SNF/TCU facilities where I’ve done sub-acute/ OP/ LTC, and interned in one other, and have had multiple friends and colleagues who have worked in similar facilities, mostly for the major companies, and the only way I have encountered productivity billing is the way I described above. I can tell you that productivity demands that I have seen, experienced, and heard of take into account the hours paid that you worked, not your vacation time, CEU, etc, and it ranges from 65% to 92%. If anyone else has had a different experience in how productivity is calculated they can comment on that and the impact on them; again, I want to comment on what I’ve seen and experienced.Why it makes me sad:

Productivity is often what we are judged by, and it is often all about the money, not about the patient or outcomes. I understand this is a business (see my previous posts about the WSJ article on “copious therapy”). But seriously, productivity of 94%? To me, that sounds like a company looking at a bottom line with such a myopic view (for shareholders?) that they don’t see what they are doing to their staff.

Why it makes me angry:

What to fit in the minutes left over in the day: Using the productivity calculation above, in working an 8 hour day, if you factor our your LEGAL two 15 minute breaks (who really takes those?), and you DON’T document on your lunch, and you don’t overlap patients (which you can do with commercial insurance, but not Medicare): at 65% you have 138 minutes left, at 70% you have 114, at 75% you have 90, at 80% you have 42, at 90% you have 48, at 92% you have 8 minutes. In those remaining minutes, you need to get ready for the day, go between patients (hopefully your patients aren’t spread out in a large facility), document to facility and payor expectations (or at least complete what you didn’t do during point of service documentation), return phone calls, respond to emails, talk to families who stop you in the hallway, talk to other disciplines you work alongside, breathe, and wrap up for the day (bathroom and water breaks are covered during your personal breaks). I forgot to mention staff meetings (which may be factored out for efficiency, but not productivity), supervising PTA’s and co-signing their notes, waiting for nursing to give meds or finish toileting or dressing, finding patients unavailable due to an MD/NP seeing the patient, the patient refusing for a variety of reasons, the patient being out of the facility, finding OT or SLP has your patient, and answering the occasional call light, and I’m sure there is more that I’m not thinking of at the moment, all while trying to keep your focus on service, patient satisfaction, and good working relationships and not allowing your productivity requirements become the focus and becoming self-centered/ serving.

Would I rather have 138 minutes to do all that, or 8 minutes? Some companies use transporters, which helps. There are questionable suggestions/ recommendations I’ve heard that give me pause in even considering working for a national company that requires the higher levels of productivity. And if a therapist can’t achieve those levels, their options would to: a) be fired, b) document off the clock, or c) try to find a company more in line with their views (my boss and her boss will probably read this – Brenda and Amy I love our company, have no issues, have no intention of leaving, and welcome a discussion on how to improve my productivity!).

Why it makes me scared:

We have done this to ourselves, and I see no end in sight. We as therapists have valued and needed a paycheck, and not stood up and said enough is enough. And for those that have said enough, someone has always been willing to come behind and take the job (at less pay such as a new grad with their student loans coming due).

What can we do?

For the benefit of therapists and our profession:

Refuse to document off the clock.

Do not work for companies with productivity standards that are so high that we document off the clock or be unethical in practice. I personally have limited who I work for to companies that put people before profit (people being patients and staff), while still encouraging their therapists to ethically do and be their best. For students interested in geriatrics, I don’t give company names that I won’t work for, but I offer suggestions of what to look for and questions to ask any employer.

HOWEVER! As altruistic as we want to be, healthcare is a business. Whether big business and answering to shareholders (ala RehabCare/Kindred) or a non-profit, you can’t run in the red. We as professionals need to determine (and stand up for) what is ethical, but also be aware that this is a business; companies, it may help to show us the business numbers for better understanding and buy-in. We need to ethically (and legally) be as productive as we can. That may be structuring our day better (not checking/ answering emails except at specific times, seeing patients in a “geographic” sequence to limit getting our 10,000 steps a day by lunchtime, etc), thinking about using a productivity system or framework at work (Getting Things Done, Six Sigma, Kaizan, etc) not having non-work discussions during non-break time, trying point of service documentation as much as we can, giving our employers ideas on how to improve productivity to address roadblocks we encounter, etc.

I wish things were different, and hope things get better for the sake of our patients and our profession. In the meantime if we are having a difficult time with productivity demands, we need to follow our ethical principles while either working with our employer to see the issues or look for another job that will value us and what we bring to the table, not just the number we generate (and be thankful when we find that job!).

Sorry for the length of my thoughts and opinions – I would be interested to hear other takes on productivity calculations, how to be more productive, ethical considerations in productivity, etc, be it on a listserv, FB, Twitter, or the comments section below.
Photo credit: Productivity by Sean MacEntee

Disclaimer before I go further – I work at a wonderful place that listens to its therapists’ recommendations regarding level of minutes. They respect our professional recommendations and we work together to deliver what is appropriate, adjusting levels as needed. I am very thankful to be working there; this blog especially this post and the next one are my thoughts and do not reflect the thoughts, positions, or practice of the staff or management.

On Monday August 17th, The Wall Street Journal had a page 1 article entitled “Nursing-Home Rehab Raises Medicare’s Tab” with the subtitle online of “Medicare pays top dollar for patients in heavy rehab; the pivotal 720-minute mark” and in the paper “Federal rules can give homes financial incentive to provide ‘ultra high’ therapy.” For those who don’t have access, I will give you an overview in this post [along with a few comments], then provide a few thoughts on the article.

The article leads with a story of a 96-year-old gentleman in California who had fallen and broken his hip, had it surgically repaired, and then went to a SNF/TCU for rehabilitation. He “became severely dehydrated… in part because staff did not follow written plans for his nutrition or facility policies… still, during many of his 21 days there, the 96 year old man suffering from dementia received 2 hours or more of [PT and OT] combined.” This gave the nursing home an “ultra-High” level for rehab, billing Medicare “top dollar for his entire stay.”

Medicare use to pay based on costs, but in 1998 it adopted a new payment system based on categories, which the article points out has been billed at higher levels with increasing frequency. In 2002 the average use of RU for billing was 7% nationwide, and in 2013 it was up to 54%. The categories with corresponding minutes/week and 2013 reimbursement rates are below (I added the minutes per day per discipline).

Category

Number of minutes/wk

Reimbursement in 2013 (WSJ)

Minimum minutes/day with 2 therapies (5 days a week)

Minimum minutes/day with 3 therapies (5 days a week)

RL

45-149

$325/day

RM

150-324

$341/day

RH

325-499

$383/day

33 each

RV

500-719

$445/day

50 each

33 each

RU

720

$560/day

72 each

48 each

According to Vincent More (Brown University health services professor, and chairman of the independent quality committee at HCR ManorCare Inc), the new system “‘changed the incentives which changed the culture… playing to the max has a long tradition in health care – that tradition is based on the number of minutes of therapy given, so people give therapy up to the max.’ He says factors such as a trend of sicker patients getting admitted to nursing homes may also contribute to rising therapy.” While he acknowledges the benefits of therapy he admits that we don’t know if outcomes are better with higher minutes. The article notes that this payment system causes problems, with dozens of interviews (former and current therapists, rehab directors and others who provide care in 17 states) revealing pressure to reach the 720 minute mark. This delivery of therapy even occurs “when patients are unresponsive, aren’t likely to benefit or have declined such services” [some therapists talk about this pressure; more about this in my next post].

This high level of billing occurs across the country, in small sites and large chains, with several chains mentioned (Genesis, Kindred, HCR, and Five Star Quality Care); HCR is being sued by the DOJ for allegedly pressuring employees to provide unnecessary therapy and overbill Medicare (HRC “refutes the basic claims” and states that they provide care “based on [patients’] individual clinical needs.”).

Industry defenders such as David Gifford (senior VP at the American Health Care Association) believe the WSJ analysis “is incomplete because it doesn’t examine patient outcomes but ‘shows we are trying to provide as much therapy as possible to get people better.’ Patients generally want as much therapy as possible [in my experience this is not common] and Medicare doesn’t set quantity guidelines he says…. Factors beyond money drive increased therapy, says Kim Blunt, an nursing home consultant and former nursing-home administrator at HCR and other organizations. Patients are more educated about health care than a generation ago, she says, and demand more therapy [again, in my experience this is not common]. Providers more thoroughly document treatment she says [point of service documentation is feasible, but would not justify the increase in RU, and can be an ethical issue depending on how it is done in my opinion], and hospitals send patients to nursing homes sooner after surgeries” [true, but often they can’t tolerate an RU when they are more sick].

Critics of the high billing practices report pressure to get as many patients as possible to the 720 minute mark, but not to go over it. Therapists are asked to provide therapy to those who refuse it, don’t need it, or are in “advanced stages of illness.” WSJ analysis of data showed that from 2010 to 2013, nursing homes billed Medicare at the RU level for at least 51,000 patients “until they went on hospice… and about 110,000 patients died within five days” of RU billing. Mr. Gilford “says many patients may need lots of therapy to prepare for home-based hospice care” [they may need therapy to be able to get up stairs or improve strength to make it home, but I haven’t seen it take an RU to do it].

The billing system was developed by Dr. Brant Fries at the University of Michigan, “using statistical methods to determine categories based on examining patients at the time because there wasn’t good science predicting how much therapy was needed. There still isn’t good science, he says, adding that he named the ultrahigh category after determining patients getting 720 minutes were “a very rare group.” Responding to the Journal’s findings, he says there may be “excesses of people getting rehabilitation””. In January the Medicare Payment Advisory Commission (independent congressional agency) and the Urban Institute released a report, stating that “the present payment system continues to encourage providers to furnish clinically-unnecessary services for financial gain.” [emphasis mine]

The article closes with more to the story of the 96 year old gentleman, with snippets of information from the OT and SLP notes over the last week of his stay there, including “no understanding or recall” of OT’s fall prevention instruction and the SLP’s report that he “is unable to hold his head up for longer than several seconds.” The day before he was sent to the hospital he became agitated and tried to hit a therapist, and received 61 minutes of PT, 50 of OT, and 60 of SLP.

I’d love to say that numbers don’t matter in healthcare rehabilitation, but this is a business and if you run your business without thinking of the numbers to some extent you won’t be around long. But has evidence for more rehab supported this dramatic increase? That is a tough question; I haven’t seen any study looking at discharge location, re-admittance rates, falls, or anything like that relating to RUG levels. But it is questionable to me with the financial incentives to provide more, and the pressures put on therapists at times to get minutes/ levels, and I don’t know that research would support the extent that RU is billed (if anyone has data, please share and enlighten me!).

So where might we go from here? This article may spur quicker changes at CMS; paying by minutes doesn’t seem to work, and MPAC/ UI’s report acknowledges the financial conflict of interest. Paying strictly by outcomes won’t work (sicker patients take longer and won’t recover as much), though G-codes make me think they are heading that way. I like the idea of FOTO, which allows comparison of patients to others with similar conditions (it is mostly an OP tool, but apparently has a SNF version). Let’s hope whatever CMS adopts is something that all parties can get behind. According to an article in the new GeriNotes, the IMPACT Act of 2014 (Improving Medicare Post-Acute Care Transformation) requires the implementation of standardized assessment data by October 1, 2018 (Home Health is extended until January 1, 2019). These data are functional status, cognitive function/ mental status, special treatments, interventions, and services, medical conditions/ comorbidities, impairments, and an “other” (any category required by the Secretary of HHS). It will be interesting to see what they will do with the data and how they will tie it into payment.

I’ve come across three interesting and intersecting publications, all pointing out to one degree or another the importance of word choice in the context of healthcare. Sometimes I get in a zone where I’m focused on the task at hand, and my use of words is either non-existent or poorly chosen, so I have found these helpful.

The first publication is from a recent con-ed I went to, put on by ISPI entitled The Low Back is Having Brain Surgery, presented by Adriaan Louw. I remember a little bit about pain in PT school, but I don’t remember anything like this. It is amazing how pictures and word choice (both pre and post-op) can impact a patient’s recovery. I’ve been more aware of my words about pain and recovery regardless of their diagnosis (and is it time to stop the “Pain and Torture” joke? It does not help either the patient or our profession). I hope I can attend several other courses as well as get a copy of Explain Pain.

The second is an article entitled The Talking Cure for Healthcare that came out in the WSJ a week after I went to the course. It isn’t about PT specifically, but communication in a medical context. Poor communication “can hurt the quality of care, drive up costs and increase the risk of lawsuits. And under new Medicare rules, providers won’t get as much money if they rack up poor patient-satisfaction scores or too many preventable readmissions…Doctors are trained to ask permission to enter a room, introduce themselves and put patients at ease. And then they should be clear about how long an exam or procedure will take, when results will be back, what they are doing and why, what patients should expect and what the plan for the future is. Before leaving, they are expected to thank the patient and family and let them know it has been enjoyable to work with them.” Wow! I think I have good patient rapport and I explain what I am doing and why, but this article was a great reminder of how I could do things differently and what to be aware of when I am more focused on the task than the person. It is about them and their recovery.

The third is a research study that I had seen mentioned on Twitter but hadn’t had an opportunity to read it until the last week or so – Cognitive Treatment of Illness Perceptions in Patients With Chronic Low Back Pain: A Randomized Controlled Trial (April issue of PTJ). This post is not meant to examine the report in detail (although it appears to have “statistically significant and clinically relevant improvements in patient-relevant physical activities at 18 weeks.”). They wanted to see if addressing the patient’s perception about their symptoms would improve their activity limitations. The intervention had four phases – examining the illness perception, challenging the maladaptive perceptions, developing alternative perceptions, and testing/ confirming the new perceptions. What I found interesting is that rather than finding an anatomical cause of the pain and then doing manual therapy, exercise, or a modality, they spent time listening to the patient and dialoging about the problem, examining the person’s beliefs about the pain, and helping them to a new belief and testing it out, and that made a difference.

Now out of school for four years, I’m almost out of the “new professional” classification, and I have grown a lot (thanks in large part to the residency). In PT school we are taught how to take a good history – how long have you had the problem, what makes it better or worse, etc so that we are good clinicians upon graduation. For me, part of becoming a better clinician is seeing how our word choice can impact a patient both in recovery as well as their satisfaction with rehab as a whole. I’ve always had good rapport with my patients (well, most of them), but these publications about the importance of words have helped me further my “soft” clinical skills.

Additionally, it was reported recently in Circulation: Heart Failure that people with heart failure are at risk for vertebral fractures, with an increase when combined with a-fib.

A few thoughts with all this recent news on fractures (and seeing patients with one or more):
First, I’m glad this information is out there, and hopefully patients and their physicians and pharmacists will assess “are all these medications needed and in this dose considering the side effects?” Second, this is a reason to take a good medical history and know what your patient is taking. This segues into #3, which is the importance of weight bearing exercise which can help reduce the risk of fractures. I wish my patients and our community at large were more adherent to physical activity recommendations, but that is a research project for later.

Thanks to Monique Serpas PT, I read an interesting article about insurance covering exercise programs. I think this should be covered or at least supplemented. Here is why, and the possible problems:

Why: more cost-effective for everyone (providing the insured does the program), better for the health of the insured (versus medications and side-effects, especially with polypharmacy), reduced disease burden not only for the country/ community, but also for the individual and their family as they age.

Problems: Adherence (how many of us join a gym but don’t make good use of it?); motivation – ties into adherence, but unless there is either a tangible reward or punishment (better health/ function, or money) I suspect there is less likelihood of participation; insurance company buy-in – because they know the stats on adherence to exercise (why pay for something most won’t keep doing?); lack of education – like Monique said in the comments, there is a lack of education and knowledge on how to lose weight or be more active safely.

Group Health (an HMO in Seattle) does this – they underwrite a good portion of EnhanceFitness for their participants, with good (published) results. I’d like to see other insurance companies do similar structured pilot programs and see what happens.